Introduction

The COVID-19 pandemic has burdened the healthcare system immensely globally and in India. The number of cases has crossed the eight million mark within eight months since the first case was reported in India on January 31, 2020 [1]. The disease outbreak has placed unprecedented demands on the healthcare system. With a population of 1.3 billion, varying levels of health system preparedness across states and union territories, and densely populated settlements of the urban poor with limited access to water and sanitation services, India is particularly at high risk [2].

As the pandemic began to spread in India, the immediate need for international not-for-profit organizations like Jhpiego was to step in and support the government at the national and state levels with innovative strategies, technical assistance, and field-based support to deal with this public health emergency. Jhpiego, a global health leader and a Johns Hopkins University affiliate, has been working in several countries including India to save lives, improve health, and transform the futures of millions of women and their families. It stepped in to provide multipronged support to the national government and more than 15 state governments to fight the pandemic.

By the time the lockdown started in India in March 2020, Jhpiego’s COVID-19 response strategy was in action. It started with three clear objectives: (1) Strengthen the knowledge and expertise of frontline health workers to deal with COVID-19; (2) support the national and state governments in their requests for COVID-19 response; and (3) ensure continuation of reproductive, maternal, newborn, child, and adolescent health services, and other essential health services.

In the early days of the pandemic, there was limited understanding about the modes of transmission of the infection. Jhpiego prepared and disseminated learning resource packages and risk communication material. To help with the continuation of essential services, virtual trainings were organized to cover facility preparedness, infection prevention, and triaging. The training material was freely shared with the National Disaster Management Authority, the Indian Nursing Council, state governments, and NGOs. Jhpiego helped government staff to interpret state-specific guidance, and it developed frequently asked questions (FAQs) and incorporated strategies to address mental health problems.

Jhpiego worked closely with various state governments to provide a rapid response to COVID-19-related needs which included mapping of essential supplies of personal protection equipment, masks, and ventilators, enabling rapid procurement of these items, and supporting state governments to assess district preparedness for quarantine and isolation facilities/wards at district hospitals for containing the highly contagious novel coronavirus.

In keeping with its mission of saving women’s and children’s lives, Jhpiego teams placed a special emphasis on ensuring that quality care was available to pregnant, laboring, and breastfeeding women. It continued to work closely with frontline healthcare workers helping them as they conducted home-based antenatal and postnatal care and provided contraceptives. Jhpiego also participated in efforts to enable continuity of care for non-communicable diseases like diabetes in pregnancy and cancer care. In some states, Jhpiego staff assisted the maternal health division to organize and operationalize maternity care services in COVID hospitals.

By mid-October, more than 50,000 people were reached through some 200 virtual training sessions across 15 states. The orientations and trainings included various cadres of health workers including doctors, nurses, paramedical staff, community-level workers, volunteers, district and state officials, tele-counselors, hospital owners, academic counselors, and even civil defense staff.

In the following sections, innovations in Jhpiego’s COVID-19 response that provided timely and critical support to national and state governments are shared.

Jhpiego’s Innovative COVID-19 Response Through NISHTHA

Jhpiego is the implementing partner for US Agency for International Development’s (USAID’s) flagship health systems strengthening program called NISHTHA. This program aims to transform primary health care (PHC) in India so that it is equitable, comprehensive, and client-centered, and improves health outcomes for India’s marginalized and vulnerable populations. A well-resourced and well-equipped resilient primary healthcare system is needed to manage COVID-19 and other public health threats. Jhpiego was fortunate to have been working at the national level and in 13 intervention states—Assam, Chhattisgarh, Jharkhand, Madhya Pradesh, Odisha, Arunachal Pradesh, Maharashtra, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim, and Tripura and so could quickly move in to provide technical assistance to strengthen the COVID-19 response. Technical assistance was planned in two phases: (1) an acute phase to address the immediate requirements and needs articulated at the national and state levels for mitigation and health system preparedness and (2) resilience and recovery phase which focuses on technical assistance to the national and state governments to gear up the primary healthcare system for resilience and enhance preparedness for COVID-19 and other infectious diseases and future public health emergencies.

NISHTHA’s training came at the right time. It was beneficial in many ways as at that time there was a lot of misinformation and chaos. The virtual training helped build capacity, dispel myths and misconceptions, and equip Jhpiego with the right knowledge.

Ms. Chetna Sharma, Community Health Officer, HWC Sagod, Madhya Pradesh

Key Strategic Projects Under NISHTHA for COVID-19 Response

The Jhpiego teams moved quickly to implement the following innovative solutions in partnership with state governments, to address COVID-19-related challenges, maintain essential health service delivery, and prevent health system collapse.

Data-Driven Intelligence Support for COVID-19 in Maharashtra

Intervention Rationale

Strengthening the response to the COVID-19 pandemic depends largely on continuous and close monitoring of the actual on-the-ground situation and outcomes of interventions to mitigate the risk of infection. Responding to public health emergencies like COVID-19 requires timely and accurate information on the number of cases, preparedness of healthcare facilities, and the availability of a health workforce. COVID-19 has reinforced the importance and need for data-driven solutions for infection control. System responsiveness had to be intensified to deal with the current pandemic. Challenges like lack of personal protection equipment (PPE), testing kits, isolation beds, intensive care units (ICUs), and medical oxygen had to be addressed [3, 4].

Tools like mathematical modeling of the disease can help in the estimation of healthcare requirements and enable a logical allocation of resources. Considering the varied spread of the virus in different cities, planning for mounting a response had to be adaptable and situation-specific. When the case numbers are relatively few, a mathematical simulation approach is best suited to understanding the epidemic and formulating an appropriate response [5, 6]. Several data repositories, along with mathematical models, have been developed overtime for academic and research purposes to predict the extent and duration of various infections [7]. However, the current pandemic situation has seen a steep increase in the use of mathematical models to analyze and predict the outbreak for planning an effective public health response.

Model Description

In order to strengthen the COVID-19 response in the state of Maharashtra, Jhpiego’s team, in partnership with its technology partner Gramener and in consultation with the state government, designed a COVID-19 data-driven intelligence engine and a citizen’s mobile application.

The intelligence engine is a combination of a comprehensive COVID-19 dashboard that provides data of the ground situation of COVID-19 and predictive modeling which forecasts the COVID-19 situation for a period of 14 days (Fig. 2.1a, b). The dashboard includes a summary of the overall picture of COVID-19 in the state including geographical distribution of cases across the state, cases across different segments of the population, and availability of testing capacities and medical supplies. Interactive data visualization enables policy-makers to view the trends and statistics at a glance and make evidence-based decisions on the preparedness of healthcare facilities, areas for rigorous testing, and other preventive measures. A subset of this dashboard is available for the general public to keep them updated on the current status of COVID-19 in the state and the health preparedness initiatives undertaken by the state government. To meet future demands on the health infrastructure, a predictive modeling dashboard was created to forecast the number of cases, the number of health facilities, and medical supplies required for an integrated response. The objective is to provide evidence for guiding policy decisions on COVID-19 and the response of government officials in the state. This modeling exercise forecasts up to 14-day projections for cases, recoveries, and deaths. Additionally, infrastructure (number of isolation beds with and without oxygen support and critical care beds) and logistic requirements (PPE kits, N95 masks, and medical oxygen) are also projected to assist in the preparations for tackling the impact of the disease on the health infrastructure. The model forecasts the number of COVID-19 cases using a combination of a polynomial regression (subset of machine learning) and composite scoring. Composite scoring combines the output best fit for the polynomial regression model and adjusts the projections to the additional independent parameters influencing the outcome of COVID-19. An additional element is built into the model called COVID-19 pro-scoring accounts for changes in the number of cases by considering a 7-day moving average of the change in rate. The data dashboard is customized to give a multi-dimensional picture of COVID-19 across all 36 districts in the state of Maharashtra.

Fig. 2.1
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Source District Health Survey (DHS) COVID-19 data dashboard

a, b Snapshot of COVID-19 data dashboard and predictive model, Government of Maharashtra.

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With enumerable options to navigate through the analysis, policy-makers have the freedom to simulate the model by changing certain input parameters. This is crucial as decision-makers can make quick inferences from the simulation and use them for taking important decisions on opening up key aspects of the economy.

Maha Swasthya Citizens’ Application

A citizen’s mobile application, Maha Swasthya, was designed to provide real-time information to the public on COVID-19 hot spots, testing, and treatment. Through this multilingual application, people can access information on each health facility including the number of available beds and ventilators as well as contact details of the key nodal officer and the health facility. The mobile application also provides advisories on COVID-19 and an option wherein people can self-assess. It helps them to identify the severity of the COVID-19 infection based on which they can take timely decisions for availing health services (Fig. 2.2).

Fig. 2.2
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Snapshot of the mobile application Maha Swasthya

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Outcome Insights

Prompt development of data analytics through digital interventions helped decision-makers monitor the impact of the pandemic in real time in the large state of Maharashtra. This tool was effectively used for monitoring the progression of the disease. It tremendously reduced data ambiguity across all levels in the decision-making chain. The forecasting tool also enabled state officials to ensure availability of necessary infrastructure and logistics in all the districts. Although forecasting was done for a shorter duration, given its precision, districts found it to be very useful for undertaking planning and preparedness activities for the immediate duration. Multiple methods were adopted by the state to disseminate the findings from the dashboard to the districts.

Alternate Platform for Risk Communication and Community Engagement: NISHTHA Swasthya Vaani

Intervention Rationale

The COVID-19 pandemic has brought in various unprecedented challenges to communities and marginalized people across India. Widespread outbreaks of COVID-19 are associated with psychological distress and mental health problems due to the loss of livelihoods, and financial insecurity among vulnerable populations. The physiological feeling of fear of infection, somatic concerns, and worries about the pandemic's consequences is compounded by the risk of adverse mental health consequences, especially in migrants crossing borders to reach their home states. Other psychiatric problems like alcoholism and substance abuse, and risky behaviors such as violence related to gender, children, and youth will likely increase in the coming months. Given the lockdown situation and physical distancing norms, many vulnerable groups (migrant workers, the elderly, and persons with disabilities) were not able to access information related to the COVID-19 situation (Fig. 2.3).

Fig. 2.3
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NISHTHA Swasthya Vaani

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Model Description

To support vulnerable communities during COVID-19, with the help of a technology partner  GramVaani, Jhpiego set up a communication platform to reach the target population through an alternate medium—the interactive voice response (IVR)-based system called NISHTHA Swasthya Vaani and linked it with appropriate care through a network of local partners. Through this intervention, risk communication messages were disseminated to vulnerable populations including migrant workers and their families, the elderly, persons with disabilities, the urban poor, and people living in remote areas, on COVID-19 preventive measures including hand-washing, treatment-seeking, countering misinformation, and social distancing. The messaging focused on mental health issues, care of the elderly, persons with disabilities, and information on relief measures and social protection schemes. Over time, it is intended that messaging will focus on information on health services for reproductive, maternal, newborn, child health, and adolescent health (RMNCH+A), tuberculosis (TB), and other health services provided by health and wellness centers (HWCs).

This is a community-led model, wherein community-level volunteers are identified from the field who mobilize the community to utilize this platform for obtaining knowledge and also for recording their grievances. The specific work includes increasing community awareness through risk communication messaging through IVR, a mobile-based application, coordinating relief measures, and ensuring social accountability. A dedicated response system reinforces information through local influencers including Panchayati Raj Institution (PRI) members, self-help groups (SHGs), and other local leaders. The intervention was implemented in five districts of two states—four in Madhya Pradesh (Guna, Rajgarh, Khandwa, and Barwani) and one in Jharkhand (Ranchi).

Outcome Insights

NISHTHA Swasthya Vaani quickly penetrated the project geographies spreading awareness on COVID-appropriate behaviors and helping people to share their day-to-day grievances. These grievances are promptly addressed by the field volunteers with the help of the local government. This technology, based on a two-way communication process, has become very popular among the target users. By October 2020, 47,249 calls were sent out and 15,753 unique users were identified through the intervention in five districts of Madhya Pradesh and one in Jharkhand.

Provision of Tele-medicine Services Across Health and Wellness Centers in Nagaland

Intervention Rationale

The COVID-19 pandemic has brought in many unprecedented challenges to the health system including the disruption of routine healthcare services. Under lockdown, travel was restricted and fear of contacting infection resulted in people not accessing health facilities for their routine health checkups. Also, as per the Government of India’s advisory, very mild/asymptomatic patients who had requisite facilities at home for self-isolation were provided the option of home isolation. COVID-19 also disrupted the continuity of essential services and limited triaging facilities to identify and refer COVID-19 patients to the primary healthcare level. This resulted in a high caseload at secondary- and tertiary-level facilities. There was a lack of services and appropriate referral mechanisms for non-critical COVID-19 cases at the primary level. Tele-medicine thus emerged as an innovative technology-based solution for delivering services to people in need, especially to families and communities living in remote areas. This technology platform was also beneficial for triaging COVID-19 patients, providing services to non-critical COVID-19 cases, and managing essential healthcare services at the primary level. The approach has also been helpful in providing health services to asymptomatic patients who were quarantined or isolated at home to periodically connect with the service providers, report their health status, and get answers to their queries and guidance on further referral and management.

Model Description

A tele-medicine service platform was set up in the state of Nagaland for providing services at the health and wellness centers to cater to the needs of the catchment population. A technology partner was engaged in connecting the hub and spokes for conducting medical consultations. Mechanisms like e-prescription are being explored through various digital platforms.

The program is involved in building the capacity of the state to establish the necessary infrastructure and deploy service providers at both the hubs and the spokes for the smooth implementation of tele-medicine services targeted to HWCs (Fig. 2.4). Currently, the focus is on preserving the continuity of essential services, providing access to quality health care in remote areas, triaging, and decreasing the pressure on secondary and tertiary care facilities. Once the COVID-19 pandemic is over, tele-medicine will focus on the provision of quality health care. This will reduce out-of-pocket expenditure for specialized services and waiting time, organize referral management, and improve health outcomes. It will gradually be transferred to the state government along with making necessary provisions for sustained resources through the National Health Mission’s Program Implementation Plan (PIP), thereby maintaining the continuity of tele-medicine services at HWCs.

Fig. 2.4
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Operational model for tele-medicine

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Outcome Insights

COVID-19 interrupted the delivery of essential healthcare services hugely affecting people’s health-seeking behaviors. Tele-medicine has proven to be effective for bridging the gap between patients and health service providers. Patients can now consult doctors at their convenience without having to travel long distances for follow-up. Until October 2020, 19 hubs and 82 spokes had been created. Around 500 consultations have been conducted so far by linking people with general and specialized clinical care.

NISHTHA COVID Sanchar—An Interactive Voice Response System-Based Surveillance and Tracking of COVID-19 Suspects and Patients in Chhattisgarh and Jharkhand

Intervention Rationale

In the absence of a vaccine and an effective treatment for COVID-19, it is critical to contain and control infection transmission through public health measures [8]. Current literature suggests that in contrast to other acute respiratory syndromes, SARS-CoV-2 can be transmitted in the absence of symptoms [9]. Therefore, case isolation at home or in the hospital is an important control measure. Isolation of cases and contact tracing were used effectively for outbreak of SARS in 2003 [10,11,12]. However, to effectively reduce morbidity and mortality due to COVID-19, it is important to put in place a mechanism for early identification of symptoms to enable immediate contact tracing, isolation, and treatment. Many state governments initially introduced strict surveillance mechanisms to ensure that those quarantined adhered to the norms and stayed at home. Active case finding and management of those placed under home isolation and follow-up of those discharged after successful treatment completion at the hospital are critically important in responding the COVID-19 pandemic.

Owing to the rapid increase in the numbers of cases and limited resources to follow up and monitor patients in the states of Chhattisgarh and Jharkhand, there was an expressed need for establishing a technology-based surveillance system to track and follow up asymptomatic patients under home isolation as well as those discharged from hospital after completion of treatment. In Jharkhand, only patients under home isolation were monitored. In Chhattisgarh, all categories of patients were followed up.

Model Description

NISHTHA COVID Sanchar, an IVR-based active surveillance system, was piloted in four high-priority districts of Chhattisgarh (Durg, Bilaspur, Raipur, and Rajnandgaon) and in the entire state of Jharkhand. In order to accelerate and supplement the state’s response to effectively engage with COVID-19 suspects/cases for early identification and treatment, the intervention was designed to track, monitor, and identify symptomatic cases among those under home quarantine and those discharged after treatment completion from hospital. This ensured timely reporting of cases to concerned nodal officers for appropriate referral and management of identified symptomatic individuals. Thus, a model prototype was demonstrated for an integrated public health response for future disease outbreaks.

All the asymptomatic COVID-19 patients who had been quarantined or isolated at home were called on a daily basis using IVR. These individuals were asked a set of questions related to the symptoms of COVID-19 through automated calls. Persons who reported experiencing symptoms on the IVR as well as those who did not were followed up subsequently through manual calls. An inbound helpline number was created for self-reporting of symptoms by the general public. All the symptomatic cases were followed up through manual calls for confirmation and were subsequently linked to the district nodal officer for referral and further management.

Outcome Insights

Using the IVR system to monitor and track COVID-19 suspects/patients is a non-conventional technique. Used in times of need and urgency, it has proven to be strategic in supporting the overwhelmed government’s healthcare system and mounting an effective response to the pandemic. In Chhattisgarh, a total of 82,346 cases, under the three categories of home quarantine, home isolation, and post-discharge, were followed up. A total of 3819 symptomatic cases were identified and linked to appropriate care for further management. In Jharkhand, 11,817 cases were followed up of which 941 symptomatic cases were identified and linked to appropriate care for further management. The intervention was successful in demonstrating active surveillance, continuous monitoring, and tracking of COVID-19 suspects and patients. Based on these learnings, the state of Chhattisgarh has improvised a technology-based system and has established home isolation monitoring cells in all its districts.

Jhpiego’s Innovative COVID-19 Response Through Reaching Impact Saturation and Epidemic Control (RISE)

Intervention Rationale

The COVID-19 pandemic has stretched hospital resources across India as is also the case globally. Even in high-income countries, emergency medicine and critical care services have been overwhelmed. Low- and middle-income countries like India have, however, been impacted more seriously [13].

The first case was diagnosed in India on January 30, 2020. The coronavirus outbreak hit its first peak in August and September. It became necessary, therefore, to create an affordable and accessible emergency medicine and critical care infrastructure across the nation. Viral respiratory diseases such as COVID-19 can result in critical hypoxic respiratory failure. Consequently, there is a high case fatality rate. Ventilator support is needed for serious cases. Lack of essential supplies and equipment such as oxygen and ventilators and a high burden of cases due to inadequate triaging which can overwhelm the healthcare system and decrease its performance are other possible reasons for high case fatality. Manpower transitioned from other departments was not able to manage complex cases. Health workers for critical care went through extreme physical and mental stress leading to decreased performance. Also, standardized treatment guidelines for the management of COVID-19 were still evolving. Lack of an enabling environment for quality care including streamlined logistics, workflow, and infection control measures, were other deterrents. Inability to use clinical data (due to the lack of systems) to report, analyze, and review data for taking decisions and the absence of a culture for interdisciplinary coordination, continuous review of quality of care, and implementation of practices for service improvement were other causes.

RISE: India’s Strategic Response

Jhpiego leads the global project Reaching Impact, Saturation, and Epidemic Control (RISE). Funded by USAID, RISE is implemented in several countries to achieve a shared vision of attaining and maintaining epidemic control with strong local partners.

As a part of the pandemic response, in coordination with the Government of India and the Indian Red Cross Society, USAID donated 200 portable ventilators to assist India in its fight against COVID-19. In addition to ventilators, USAID through RISE supported the provision of technical assistance to the Government of India in capacity building, system strengthening, and ensuring optimum utilization of the ventilators, along with building an enabling environment for critical care of COVID-19 patients. The goal of technical assistance was to improve and standardize intensive care for severely ill COVID-19 patients by identifying potential areas of improvement.

Technical assistance provided to the intervention facilities had a four-pronged strategy. The first strategy was to build the capacity of healthcare providers and develop their competency through asynchronous learning by providing online content that could be accessed when it best suited their schedules. The second strategy was to optimize clinical care by sharing experiences, developing standard operating procedures and management protocols, and enhancing knowledge by developing e-learning modules. The third strategy was to prioritize the use of data for action by identifying e-dashboard indicators for the critical care unit. The fourth strategy was to provide an enabling environment for critical care including efficient ventilators and a strengthened supply chain for commodities.

Jhpiego initiated its activities in August 2020 with an aim to provide technical assistance to 29 recipient facilities in 15 states and three union territories and to create an ecosystem for the efficient utilization of the 200 portable ventilators donated by USAID.

Using a hub-and-spoke model, in collaboration with the National Health Mission, Government of India, state governments, and regional intervention facilities, it was decided to build the capacity of several other facilities in critical care management for COVID-19 (Fig. 2.5).

Fig. 2.5
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Recipient facilities across India

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Engagement with Critical Care Working Groups

In order to build a system for interdisciplinary coordination, there was a continuous review of quality of care and implementation of practices for service improvement, and Jhpiego established facility-based Critical Care Working Groups (CCWGs) to provide oversight and standardize care for critically ill COVID-19 patients in the facilities. CCWGs were able to provide interdisciplinary inputs. They were effective in ensuring safe adoption of new management protocols for COVID-19 and facilitating the upscaling of this approach. The CCWGs met twice a month to discuss opportunities and challenges and  with  the experts from other institutions to promote cross-learning, exchange ideas, and share knowledge. By October 30, RISE had facilitated the formation of CCWGs in 9 facilities including the All India Institute of Medical Sciences (AIIMS) Jodhpur, AIIMS Patna, AIIMS Rishikesh, AIIMS Nagpur, AIIMS Bhopal, AIIMS Gorakhpur, Institute of Medical Sciences (IMS), Banaras Hindu University (BHU) Varanasi, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences, Shillong, and the Railway Hospital Chakradharpur. CCWGs already existed in AIIMS Bhubaneswar and AIIMS Bhopal.

Situational Assessments Using Specific Tools

Situational assessment was undertaken to identify specific needs and to contextualize intervention strategies prior to initiating implementation. Situational assessments were conducted jointly by members of CCWG and the RISE India team in the months of September and October 2020. By the end of September 2020, situational assessments had been completed in six Tranche-1 facilities and twelve Tranche-2 facilities. RISE India developed two tools for use in these assessments: (1) a facility situational assessment tool to understand the existing needs of the facility in critical care and to assess the existing critical infrastructure, trained human resources, logistics, and availability of policies and protocols and (2) a knowledge assessment tool which was a self-assessment tool for providers involved in critical care. It was developed to identify self-perceived needs of the providers in capacity building.

Strategic Interventions Under RISE

The formation of the CCWGs remained the crux of all the strategic interventions planned under RISE, and through these facilities-based groups, program strategies and interventions were planned and contextualized to address specific bottlenecks and gaps identified during the situational assessment. RISE is an ongoing program. As the pandemic evolves, the strategies will also evolve based on need. The following are some of the strategies that were implemented to address the current needs.

Capacity Building

Jhpiego initiated building of the clinical capacity of facility-based, multi-disciplinary teams for COVID-19 case management by following different contextualized approaches to enable the facilities to manage a surge in the case load.

Capacity Building Network

Healthcare facilities were classified into three levels based on their training capacities and their status as COVID facilities in order to develop an interconnected network of these facilities with a focused approach for capacity building for each level in a phased manner. The facilities were divided into three programmatic levels based on their status as COVID facilities and their ability to train human resources. Eleven tertiary COVID facilities with existing training capacity were considered as Level 3 facilities that could mentor lower-level facilities on focused training capsules for COVID care. Eleven tertiary and secondary COVID facilities requiring capacity building were considered as Level 2 facilities which could be trained on critical care management by Level 3 facilities and could support Level 1 facilities. The remaining seven secondary non-COVID facilities requiring capacity building were considered as Level 1 facilities that would require preparatory capacity building support through Levels 2 and 3 facilities.

Hub-and-Spoke Model for Training and Mentorship

The hub-and-spoke model is a unique model for capacity building, wherein some of the Level 3 facilities disseminate knowledge, practice, and experiences in managing COVID-19 patients to facilities including non-RISE intervention facilities such as the dedicated COVID health centers (DCHCs)Footnote 1 and the dedicated COVID hospitals (DCHs) in the state. The four identified hubs under RISE were AIIMS Bhopal, AIIMS Raipur, North Eastern Indira Gandhi Regional Institute of Health and Medical Sciences (NEIGRIHMS), Shillong, and AIIMS Bhubaneshwar. The spokes for each hub were defined by the respective state governments and the hub facilities. The hubs helped the states in formulating standard operating procedures and guidelines for intensive care units (ICUs). The hubs actively helped the states in forming working groups and define the scope of work for these groups. These mentorships used contextualized methodologies for training webinars, hands-on orientations at skill stations, and classroom-based didactic sessions (Fig. 2.6).

Fig. 2.6
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Three levels of COVID facilities

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By October 30, 2020, eight batches of hands-on workshops on ‘Critical Care Management of COVID-19 Patients’ were organized at AIIMS Bhopal, Center of Excellence for Clinical Management of COVID-19, to train 83 doctors and 82 nurses. This initiative was jointly supported by the National Health Mission, Directorate of Health Services, Directorate of Medical Education, Madhya Pradesh, and RISE India.

e-Grand Rounds

Using a virtual platform, the e-Grand rounds provided a unique opportunity to doctors to improve their care giving skills through clinical case discussion with peers. The e-Grand rounds were used to present and discuss specific COVID-19 cases, share experiences, and seek expert opinion from a panel of experts. The e-Grand rounds also served as platforms to share updates on treatment and management protocols, promote knowledge sharing, and as the pandemic evolved, review new evidence and changing epidemiology.

The first e-Grand round on ‘Clinical Challenges in COVID-19 Management,’ organized by the Jhpiego team and conducted by AIIMS Patna on September 21, 2020, was attended by 103 critical care providers from 20 medical institutions, including the 10 regional AIIMS. Two clinical cases were reviewed and discussed in this workshop.

e-Learning

Healthcare providers, like doctors and nurses involved in active COVID-19 duty, often found it challenging to attend physical in-person training sessions due to their work schedules. To counter this challenge, it was decided to use asynchronous e-learning or a hybrid training package which was formulated after identifying program needs of specialists, medical officers, nurses, and paramedics by the CCWG at the supported facilities. The virtual training package allowed healthcare providers to take the training as per their convenience. Training covered topics related to infection prevention and control, general triage, and clinical management of hospitalized COVID-19 patients. Trainings were supported by electronic simulation of critical care and e-mentoring.

On 4th September, I was on night duty in the ICU and the Zoll Ventilator suddenly showed a low battery charge of 25 percent. We feared that we may have to shift the patient but the training which was conducted by the RISE team on the operations of the ventilator was very helpful in providing the requisite guidance to troubleshoot and recalibrate the ventilator machine thus saving the patient's life. I thank Dr Ashwini Kumar (from RISE India) for insisting that I attend the training program. Otherwise, I may not have been able to save a life. Thank you RISE team!

Ajay Pal Singh, Nurse In-charge COVID ICU, AIIMS Jodhpur

Data for Action e-Dashboards

Jhpiego provided support in developing a process for data collection, data management, and data analysis which could be used across facilities and the healthcare system for improved decision-making. The e-dashboards utilized data from existing care processes for decision-making and helped in monitoring pandemic responses across facilities. These dashboards were developed in consultation with the CCWG and were customized for each facility, contextualizing the requisite quality indicators and available data sources from care processes. This allowed regular monitoring and tracking of varoius indicators.

Building an Enabling Environment

Logistics

The Jhpiego team provided support to facilities for the procurement process for COVID-19-related commodities and also ensured the availability of consumables required for the ventilators donated by USAID. Jhpiego worked with some states like Madhya Pradesh for allocation of additional budgets to ensure the provision of PPEs and to further strengthen the ICUs.

Troubleshooting

RISE India provided troubleshooting support to facilities by coordinating with them and the manufacturers and installers of the USAID-donated ventilators, as and when the need arose.

Outcome Insights

Within a period of 75 days, the RISE program was able to conduct capacity building interventions for 343 healthcare providers who worked  at the  critical care unit or were  planned to be posted at the  critical care unit for COVID-19. These included 125 nurses and 218 doctors working in the facilities to improve the ICU environment. Emergencies such as COVID-19 require a rapid response to address existing systemic gaps. RISE was able to achieve this by using a multipronged approach through partnership with various stakeholders supporting critical care. It was thus able to save lives. While infrastructure gaps like the lack of ventilators could be addressed through immediate financial allocations, filling the requirement for trained and skilled human resources requires long-term commitment. With an ensuing second wave of the disease, there was a strong need to ramp up all preparatory activities including those for capacity building and ensure the availability of trained and skilled human resources to support critical care needs.

Jhpiego’s Efforts in Safeguarding Quality Maternal Care in India’s Private Healthcare Facilities During COVID-19 Pandemic

At the time when healthcare systems were overstretched in dealing with the COVID-19 pandemic, the skills, competence, and confidence of frontline healthcare workers, and hospital preparedness to ensure that women and newborns continue to get quality care, is important.

In India, one out of every three facility births occurs in private institutions. With support from Merck Sharp and Dohme (MSD) for mothers and in partnership with the Federation of Obstetrics and Gynecological Societies of India (FOGSI), Jhpiego worked with private facilities in the states of Uttar Pradesh, Jharkhand, and Maharashtra to build skills, confidence, and resilience and to prepare private facilities for providing quality intrapartum and immediate postpartum care to mothers and newborns through a quality certification program called Manyata. Launched in 2013, the Manyata program responded to a glaring need to address quality of care in private maternity facilities. No national system existed for ensuring the quality of private health services. Manyata bridged this gap by ensuring that well-trained healthcare providers ensured respectful and safe experiences for mothers during childbirth, while upholding the best clinical practices. As of July 2020, there were about 700 Manyata-certified facilities, of which 390 had received quality improvement (QI) support from Jhpiego and additional 600 were enrolled to work toward the goal that no woman should die during childbirth. With the COVID-19 crisis putting an unprecedented stress on healthcare providers in public health facilities, the private sector was primed to support and complement the government’s commitment to ensure the continuation of high-quality essential services.

In the early days of COVID-19, despite numerous global and national guidelines for pregnant, laboring, and breastfeeding women, many healthcare providers were unsure how to provide care to mothers and their newborns safely. By the first week of March 2020, Jhpiego had orientated the staff of Manyata-registered and certified facilities to prepare them for COVID-19. A comprehensive orientation, conducted virtually, focused on infection prevention and control measures while upholding the principles of respectful maternity care. This was followed by skills updates and discussion forums.

Jhpiego began with conducting online sessions on ensuring preparedness of facilities during the COVID-19 pandemic for the members/non-members of the Manyata family. From March to May 2020, about 650 doctors and staff from 290 facilities benefited from the orientations.

The COVID-19 pandemic has accelerated the use of digital and tele-health platforms and has digitized the delivery of QI to address the pandemic which holds great promise. Realizing the need of the hour, as physical visits for handholding of the facilities for QI under Manyata were not possible, Jhpiego utilized the initial period of the lockdown to adapt the mentoring and support visits (MSVs) for the virtual medium and ensured that all the facilities which had initiated MSVs could complete their QI package. Prior to the pandemic, few providers engaged in virtual trainings. However, there was a large increase in digital engagement as local providers and facilities adapted to the pandemic working environment to maintain high-quality care and keep the patients and themselves safe. In collaboration with Extension for Community Healthcare Outcomes (ECHO) plateform-India, Jhpiego converted the entire QI package into a structured IT-friendly learning and mentoring package for the  12-week modules. About 1000 doctors and nurses participated in these COVID-19 briefings across 248 Manyata facilities in the three states that are currently being supported by Jhpiego.

Even under normal circumstances, a mother and her baby are most vulnerable during childbirth. But the COVID-19 pandemic significantly increased the risk for pregnant and breastfeeding mothers and their infants, possibly undoing the progress India had made in reducing maternal mortality [14, 15]. Investment in continuous quality improvement and support from the Manyata team in establishing its COVID-19 preparedness protocols kept the Manyata facilities ahead of the curve in their response to the pandemic.

‘We learned to recognize the symptoms of COVID-19. We didn’t know about them that well [prior to the Manyata COVID-19 session],’ said nurse Promila. ‘Through Manyata, we have received full support and information… My staffs’ fear were removed because of this. They knew how to look for signs of COVID and prevent infection from spreading,’ said Dr. Priya.

In Maharashtra, the Indian state most impacted by the pandemic, Dr. Karthikeya Bhagat of the Manyata-certified Grace Maternity and Nursing Home in Kandivali (West), Mumbai, said, ‘I am amazed at the way they [nurses] are managing the hospital in this time of COVID-19. They are asking the right questions to patients on the phone and in person. They are conversing confidently and reporting sensibly. They are sure about what they are doing and understand the actions to be taken to conduct safe deliveries at this time [16].’

Leaders of facilities who had gone through the Manyata journey championed the program, especially when they saw the benefits of its focus on quality. ‘Because Manyata deals with clinical standards and because it specifically deals with staff nurses, it has a great advantage in a situation of a pandemic like COVID-19 where you need to put in many more measures. But if you are unsure of your routine work, then those measures will not work too well or you will find it more difficult to implement additional precautions. Every facility should get Manyata-certified,’ said Dr. Bhagat.

This quarter, due to the COVID-19 pandemic, business was not as usual. Jhpiego was quick in ensuring that the QI process changed from an on-site mentoring approach to a total e-mentoring approach. Once the COVID-19 situation eases, an efficient QI journey through a hybrid model of virtual learning interspersed with occasional physical mentoring visits to reduce time during the period of engagement to 3–4 months is envisaged.

Key Learnings from the Interventions

The COVID-19 pandemic posed a crisis to the health system which was intensified with the increasing number of cases. Jhpiego quickly mounted a multi-sectoral and multipronged approach to address the challenge by providing technical support to enhance preparedness capacities and resilience of the healthcare systems nationally and across 15 states of India. Several cross-learning opportunities were created during the rollout of interventions. Of all the conventional and technology-based approaches, technology emerged as a clear winner. Jhpiego’s experience of training various categories of healthcare workers and managers showed that using virtual platforms for training and mentoring was effective for transmitting knowledge as well as for developing skills. The need to invest more in health workforce protection and capacity enhancement was clearly highlighted. Co-designing local solutions for local problems by following a decentralization approach were very effective. Risk communications, with a focus on basics, had a multiplier effect. Community-centered, community-owned, and community-driven solutions are needed to achieve self-reliance. These are summarized below:

  • Digital technology—Digital solutions play a pivotal role and can be used for innovative service delivery, mentoring, and counseling through tele-medicine.

  • Health workforce protection—Enhanced health protection and building competencies to cater to public health emergencies.

  • Innovations—Deployment of innovative solutions to accelerate access, amplify impact, make health systems resilient, and increase equity in coverage.

  • Risk communication—Strong efforts for health promotion and preventive measures, focused on basics, are simple things that can have a multiplier effect.

  • Decentralization—There is a need to focus on decentralization of services, drugs, and diagnostics to enhance access to health care and equity in coverage.

  • Communities—There is a need for community-centered, community-owned, and community-driven solutions to achieve self-reliance.

  • Resilient primary health care—Public health facilities and healthcare providers are the fulcrum of India’s COVID response. There is a need to invest more in primary health care.

Way Forward: Toward Resilient Healthcare Systems

Healthcare system resilience is defined as the capacity of the health system to prepare for and effectively respond to crises; maintain essential functions when a crisis hits; be informed by lessons learned during the crisis; and reorganize if conditions require it [17]. Health systems are resilient if they protect human lives and achieve good health outcomes for all during a crisis and in its aftermath. Response to a crisis, be it a disease outbreak or any other disruption resulting in a surge of demand for health care (e.g., a natural disaster or a mass casualty event), needs both a vigorous public health response and a highly proactive and functioning healthcare delivery system.

Beyond the acute phase of COVID-19, where the focus has largely been on mitigation and preparedness for the pandemic, Jhpiego’s comprehensive healthcare program aims to ensure mitigation of the disruption of essential primary healthcare services, including RMNCH+A and TB services, and continuity of essential health services. The program envisages providing technical assistance for building resilient primary healthcare systems through better coordination and strengthening of governance mechanisms, facility-level preparedness, piloting integrated disease surveillance mechanisms, enhancing the use of data to guide evidence-based decision-making, re-engineering and redesigning public health facilities, and setting up functional rapid response teams that can be quickly mobilized to address public health emergencies.

COVID-19 and other similar pandemics have clearly shown the need for developing the capacities of national and state governments to respond to infectious diseases in line with global guidance and international health regulations. Jhpiego worked closely with the national and state governments to plan for minimal disruption of essential services by defining service packages at the facility, community, and home-based levels of care and developing continuity of care pathways. The roles and responsibilities of the primary healthcare teams were redefined by task-sharing and task-shifting. Alternate service delivery and supply chain mechanisms to minimize the disruption of essential services in primary healthcare settings were explored.

Jhpiego plans to provide technical assistance for health workforce protection by enhancing technical knowledge and skills of the healthcare teams, supporting competency development, advocating for task-shifting/task-sharing, developing an enabling policy environment, facilitating the provisions of adequate personal protective equipment, and ensuring the mental well-being of healthcare providers.

Jhpiego’s goal is to save lives, improve health, and transform the future of women, children, families, and communities. It partners with governments, health experts, and local communities to build systems that guarantee a healthier future for women and families. Through these partnerships, it builds more resilient healthcare systems that are better prepared to deal with health emergencies and can protect all, especially the most disadvantaged and vulnerable communities.